Laparoscopic surgery is being used more frequently because it is less intrusive to the patient's body which permits shorter hospital stays. One particular form of surgery which is especially adaptable to laparoscopic surgery is gall bladder removal.
In a typical laparoscopic surgical procedure for removing a gall bladder, short incisions are made through the abdominal wall of the patient for the insertion of the surgical instruments used to perform the surgery. The abdominal cavity is bloated by pumping a gas such as CO.sub.2 into the abdominal cavity to provide the surgeons and their assistants with room to maneuver surgical instruments and a perspective from which a camera inserted into the cavity during the surgery can properly view the internal organs and abdominal wall. For each incision made through the abdominal wall, a trocar is inserted through the incision. The trocar provides a passageway for the surgical instruments through the patient's skin and abdominal wall and prevents the escape of the gas from the cavity during the surgery.
To provide the surgeon with a picture of what is occurring in the abdomen, an incision is made on the patient's umbilicus. After insertion of the trocar, a long laparoscope cylindrical lens of a camera is inserted through the trocar. The camera lens contains a light source to illuminate the organs and the picture generated by the camera is displayed on CRTs placed in the vicinity of the patient's upper body near the table. After viewing the display generated by the camera, the surgeon selects an appropriate spot on the upper right abdominal wall where a second incision is made and a trocar is inserted. This incision is used by a second surgeon or surgical assistant to aid the surgeon during the procedure. A third incision is made on the lower right side through which the second surgeon inserts instruments for assisting in exposing the gall bladder for dissection by the surgeon. The final incision is made in the upper midline (epigastrium) for the operative port through which the surgeon inserts various instruments used in performing the surgery.
To remove the gall bladder, the camera is used to locate adhesions on the abdominal wall which the surgeon removes with scrapping or cutting instruments inserted into the abdominal cavity. The liver is located and lifted to reveal the gall bladder underneath it. The cystic duct which leads into the gall bladder is clamped at a portion away from the gall bladder. The cystic artery is located and clamped to prevent excessive hemorrhaging in the abdominal cavity should a rupture of this artery occur. The gall bladder may be cut or burned loose by a laser. After the hemorrhage sites are cauterized to stop the bleeding, the gall bladder is located and pulled through the operative port in the abdominal wall. The trocars are removed and the incisions sutured. All clips, clamps, and instruments inserted in the abdominal cavity must be accounted by the surgical nurse.
While such a surgical procedure is effective for the removal of the gall bladder, ductal injuries or anatomical anomalies may not be readily discovered during such a surgical procedure. To provide the surgeon with this information during the surgery, a cholangiogram can be performed. A cholangiogram is an x-ray of the common bile duct which can alert the surgeon to previously undiscovered stones, anatomical anomalies which may require careful dissection, and ductal injuries which may lead to later complications following the gall bladder removal. If the cholangiogram is performed while the surgery is in process, the surgeon may remove the stones immediately and reduce the chance of post-operation common bile duct obstruction.
To perform a cholangiogram, a pair of micro-scissors are inserted into the abdominal cavity to dissect the cystic duct at a point between the gall bladder and where it is clamped. The micro-scissors are then removed. The surgeon inserts a gripping tool through a trocar while a nurse brings a tube leading from a syringe filled with contrast media into proximity with the cystic duct. At the forward end of the tube is mounted a cannula with a concentrically located catheter. The surgeon grips the end of the catheter extending from the cannula with the gripping tool and inserts it into the incision made by the micro-scissors. Using the inserted portion of the catheter as a guide wire, a portion of the cannula is inserted into the cystic duct. A clip is placed around the cannula and cystic duct to prevent leakage when the contrast media is injected.
At this point, all medical personnel except the surgeon and a technician leave the operating room. The technician places an x-ray film cassette under the patient's back and brings a mobile x-ray unit with a flexible C-arm over the patient's abdomen in the vicinity of the gall bladder. The surgeon then injects the contrast media through the tubing and catheter into the cystic duct which leads to the gall bladder. As the contrast media is injected, the technician takes a cholangiogram. After the technician has replaced the cassette with another one, the surgeon begins another injection so the technician can take a second cholangiogram. The technician removes the mobile x-ray machine and the other members of the operating team return.
The surgeon removes the clip from around the cannula and grips the cannula to remove it and then the catheter is withdrawn from the cystic duct. The nurse removes the tubing from the patient's abdomen through a trocar and the surgical procedure may proceed. The technician develops the cholangiograms and returns to the operating room to display them on light tables in the operating room. The surgeons may view them to ascertain if any additional surgical procedures are necessary.
While the information produced from a cholangiogram is important and useful to surgeons, very few surgeons conducting laparoscopic gall bladder removals regularly take them. This reluctance arises from the difficulties encountered in performing the procedure for taking cholangiograms. Most of the problems stem from the coordination required between the surgical team members to grasp and insert the catheter into the small incision in the cystic duct. This cooperation between team members is not only difficult because they must view the CRT to coordinate their instrument movements within the abdominal cavity, but they must manipulate articles that are very small. The diameter of the catheter is smaller than fish line and the incision in the cystic duct is correspondingly tiny. Such a procedure is roughly comparable to two people attempting to thread a needle by using barbecue tongs to hold the needle and thread. In some cases, inserting the catheter into the cystic duct through the small incision may take 30 minutes or longer. Such a time interval almost doubles the time necessary for the removal of a gall bladder.
What is needed is an expeditious method for performing a cholangiogram during a laparoscopic surgical procedure. What are also needed are instruments with which the surgical personnel can better coordinate their interactions to perform the cholangiogram.